Intensive care unit stay of more than 14 days after cardiac surgery is associated with non-cardiac organ failure

Some studies have shown an association between a prolonged intensive care unit (ICU) stay and risk factors such as mediastinal re-exploration, advanced age, low ejection fraction, lung disease and organ failure. The aim of this retrospective study was first to evaluate peri-operative risk factors (n = 2683) and secondly to evaluate long-term survival (n = 2563) in cardiac surgery patients with an ICU stay > 14 days. Long-term survival was assessed in an observational 3-year follow-up study. An ICU stay of > 14 days was associated independently with respiratory failure and dialysis-dependent acute renal failure, and with a significantly lower survival rate. Since an ICU stay is associated with a higher hospital and long-term mortality, measures should be taken throughout the entire hospital stay to identify and reduce the risk of organ failure.     

Intensive care unit outcomes in elderly cancer patients

As the number of elderly patients receiving oncologic therapies increases, the need for better outcome predictors for the critically ill elderly with cancer increases. Physicians should not view age as an indicator of poor ICU outcome, as many elderly patients with cancer will derive the same benefit from intensive care as their younger counterparts. Such a gain can be accomplished without overuse of valuable resources. Similar prognostic factors that are applied to the younger cancer patients should also be applied to the elderly. These parameters, in addition to clinical judgment, can be helpful in deciding who will benefit from ICU care regardless of age. Oncologists and critical care physicians will need to collaborate and change the paradigm of ICU care for the elderly.     

Preventable readmission to intensive care unit in critically ill cancer patients

BACKGROUND: Readmission to intensive care unit (ICU) after discharge to ward has been reported to be associated with increased hospital mortality and longer length of stay (LOS). The objective of this study was to investigate whether ICU readmission are preventable in critically ill cancer patients.METHODS: Data of patients who readmitted to intensive care unit (ICU) at National Cancer Center/Cancer Hospital of Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC) between January 2013 and November 2016 were retrospectively collected and reviewed.RESULTS: A total of 39 patients were included in the final analysis, and the overall readmission rate between 2013 and 2016 was 1.32% (39/2,961). Of 39 patients, 32 (82.1%) patients were judged as unpreventable and 7 (17.9%) patients were preventable. There were no significant differences in duration of mechanical ventilation, ICU LOS, hospital LOS, ICU mortality and in-hospital mortality between patients who were unpreventable and preventable. For 24 early readmission patients, 7 (29.2%) patients were preventable and 17 (70.8%) patients were unpreventable. Patients who were late readmission were all unpreventable. There was a trend that patients who were preventable had longer 1-year survival compared with patients who were unpreventable (100% vs. 66.8%, log rank=1.668, P=0.196).CONCLUSION: Most readmission patients were unpreventable, and all preventable readmissions occurred in early period after discharge to ward. There were no significant differences in short term outcomes and 1-year survival in critically ill cancer patients whose readmissions were preventable or not.     

More men than women are admitted to 9 intensive care units in British Columbia

Purpose

The aim of this study is to determine if more males than females are admitted to adult intensive care units (ICUs).

Materials and methods

In 9 tertiary and community hospitals in British Columbia, Canada, we expressed the number of patients admitted to hospital and to ICU from 1998 to 2008 as a proportion of the population of the main regions served by these hospitals, and for ICU patients in 1 tertiary hospital, as a proportion of the hospital population. Patients not residing in the region of this tertiary hospital or whose addresses were unknown and admissions for sex-specific diagnoses were excluded from the main analyses. Male proportion was divided by female proportion for age groups by decade. Multivariate regression was used to determine the association between sex and admission to ICU after adjustment for confounders.

Results

Normalized male-to-female ratio of ICU admissions to the 9 hospitals was greater than 1. In the tertiary hospital analyzed in more detail, the male-to-female ratio for admissions to hospital or to ICU, normalized to the population in the community or hospital, respectively, was greater than 1 for all age groups, and this ratio increased with age. After adjustment for covariates, males and females less than 80 years of age were roughly equally likely to be admitted to ICU from hospital, but in patients aged 80 or older, men were much more likely than women to be admitted (odds ratio, 2.14; 95% confidence interval, 1.56-2.94).

Conclusion

More men than women are admitted to ICUs; this difference is especially prominent in elderly patients.     

青年急重症患者在急诊监护室住院体验的研究

目的深入了解青年急重症患者入住急诊监护室期间的体验,为进一步提高护理质量提供理论依据。方法采用质性研究中的现象学研究方法,对5名在急诊ICU住院时长超过15 d的青年急重症患者进行深度访谈,并对访谈内容进行分析。结果访谈结果共提炼出5个主题:舒适感被破坏、安全感严重缺失、对与亲友分离感到焦虑、自理能力的改变带来巨大心理落差、对自我及生命的反思。结论急诊ICU的住院经历给青年急重症患者带来许多负面体验,进一步了解这些负面体验的不同层次,有助于为医护人员更好地护理青年急重症患者提供指导和方向。     

Intensive care unit patients with acquired immunodeficiency syndrome and Pneumocystis carinii pneumonia: suggested predictors of hospital outcome

OBJECTIVE: To define our ICU experience with AIDS patients, Pneumocystis carinii pneumonia, and respiratory failure, and to delineate factors predictive of hospital survival. DESIGN: A retrospective study in which logistic regression analysis was applied to data obtained during the first 144 hrs of ICU admission. SETTING: A university hospital medical ICU associated with a national AIDS treatment center. PATIENTS: Twenty-seven male patients with AIDS, P. carinii pneumonia, and respiratory failure who desired full supportive and resuscitative care. MEASUREMENTS AND MAIN RESULTS: Of 27 patients who met study criteria, 19 (70%) were nonsurvivors and eight (30%) were survivors. The relative risk of death was 2.2 times greater in patients who exhibited the combination of pH less than 7.35 and a base deficit greater than 4 mEq/L, at any time in their ICU course, than in patients who did not (95% confidence interval = 1.01, 4.81). Furthermore, the relative risk of death was 3.7 times greater in patients who required positive end-expiratory pressure greater than 10 cm H2O after 96 hrs of ICU care than in those patients who did not (95% confidence interval = 1.09, 12.33). Indices of oxygen transfer, severity of chest radiograph abnormalities, concurrent lung infections, and most laboratory studies on hospital admission were not different between the two groups nor predictive of hospital survival. CONCLUSIONS: When dealing with AIDS/P. carinii pneumonia/ICU patients, it is not possible to distinguish who will survive to hospital discharge based on information routinely available before ICU admission. Those patients with the greatest chance of survival demonstrate a significant decrease in the required level of respiratory support within the first 4 days of ICU care. The presence of a metabolic acidemia (pH less than 7.35 and base deficit greater than 4 mEq/L), at any time during the ICU course, is a poor prognostic sign. We suggest that such objective variables should be included in the development of any new outcome predictor model for this group of ICU patients.     

艾滋病患者超长住院时间的影响因素及对策

目的分析住院时间超30 d的艾滋病患者临床特征及影响因素,为制定缩短住院日的对策提供依据。方法回顾性分析重庆市公共卫生医疗救治中心感染科2018年1月1日-12月31日连续住院时间超过30 d的艾滋病住院患者,并进行数据整理及分析,探索导致艾滋病患者住院超30 d的危险因素。结果2018年感染科出院艾滋病患者共879例,其中住院超30 d患者124例,占14.1%,男女比例3∶1;124例中住院前未启动抗HIV治疗人数为90例(72.6%),CD4+T细胞<200/L 107例(86.3%),入院时患者病情一般117例(94.4%),危重7例(5.6%)。住院超30 d的艾滋病患者平均住院日为44.7 d。单因素分析显示肝功能损伤、结核病、肺炎、中枢神系统感染、输血、医院感染、营养不良均是影响住院超30 d的危险因素。多因素分析结果显示影响超长住院时间的独立危险因素是中枢神经系统感染。住院超30 d患者1年后的转归较差。结论对于艾滋病患者,做到早发现、早治疗,积极控制机会性感染,缩短平均住院日,降低住院费用,建立健全随访机制,降低死亡率。     

Supporting families of technology-dependent patients hospitalized in a pediatric intensive care unit

Having a child hospitalized in the PICU is a stressful event and may be even worse for parents when their child is technology dependent. These parents are often experts at knowing their child, are used to being strong caregivers and advocates for their child, and may experience long-term sorrow or grief over their child's lifespan. Although there is little research about effective PICU nursing interventions for this parent group, several suggestions can be inferred. Armed with this knowledge, the PICU nurse can be instrumental in helping these parents decrease their stress and improve coping skills not only for dealing with the child's PICU stay but also for improving their experiences at home.     

Intensive care unit-acquired neuromyopathy and corticosteroids in survivors of persistent ARDS

Objectives  To determine the incidence and outcomes of intensive care unit-acquired neuromyopathy and to investigate the role of methylprednisolone in survivors of persistent acute lung injury. Design  Secondary analysis of completed randomized placebo-controlled trial. Setting  Twenty-five hospitals in the NHLBI ARDS Network. Patients and participants  Patients enrolled in the ARDS Network study of methylprednisolone versus placebo for persistent ARDS who survived 60 days or to hospital discharge. Measurements and results  One hundred and twenty-eight study patients survived 60 days. Forty-three (34%) of these patients had evidence by chart review of ICU-acquired neuromyopathy, which was associated with prolonged mechanical ventilation, return to mechanical ventilation, and delayed return to home after critical illness. Treatment with methylprednisolone was not significantly associated with an increase in risk of neuromyopathy (OR 1.5; 95% CI 0.7–3.2). Conclusions  ICU-acquired-neuromyopathy is common among survivors of persistent ARDS and is associated with poorer clinical outcomes. We did not find a significant association between methylprednisolone treatment and neuromyopathy. Limitations of this study preclude definitive conclusions about the causal relationship between corticosteroids and ICU-acquired neuromuscular dysfunction. This article is discussed in the editorial available at: doi:.     

Intensive care unit delirium is an independent predictor of longer hospital stay: a prospective analysis of 261 non-ventilated patients

Introduction

Delirium occurs in most ventilated patients and is independently associated with more deaths, longer stay, and higher cost. Guidelines recommend monitoring of delirium in all intensive care unit (ICU) patients, though few data exist in non-ventilated patients. The study objective was to determine the relationship between delirium and outcomes among non-ventilated ICU patients.

Method

A prospective cohort investigation of 261 consecutively admitted medical ICU patients not requiring invasive mechanical ventilation during hospitalization at a tertiary-care, university-based hospital between February 2002 and January 2003. ICU nursing staff assessed delirium and level of consciousness at least twice per day using the Confusion Assessment Method for the ICU (CAM-ICU) and Richmond Agitation-Sedation Scale (RASS). Cox regression with time-varying covariates was used to determine the independent relationship between delirium and clinical outcomes.

Results

Of 261 patients, 125 (48%) experienced at least one episode of delirium. Patients who experienced delirium were older (mean ± SD: 56 ± 18 versus 49 ± 17 years; p = 0.002) and more severely ill as measured by Acute Physiology and Chronic Health Evaluation II (APACHE II) scores (median 15, interquartile range (IQR) 10–21 versus 11, IQR 6–16; p < 0.001) compared to their non-delirious counterparts. Patients who experienced delirium had a 29% greater risk of remaining in the ICU on any given day (compared to patients who never developed delirium) even after adjusting for age, gender, race, Charlson co-morbidity score, APACHE II score, and coma (hazard ratio (HR) 1.29; 95% confidence interval (CI) 0.98–1.69, p = 0.07). Similarly, patients who experienced delirium had a 41% greater risk of remaining in the hospital after adjusting for the same covariates (HR 1.41; 95% CI 1.05–1.89, p = 0.023). Hospital mortality was higher among patients who developed delirium (24/125, 19%) versus patients who never developed delirium (8/135, 6%), p = 0.002; however, time to in-hospital death was not significant the adjusted (HR 1.27; 95% CI 0.55–2.98, p = 0.58).

Conclusion

Delirium occurred in nearly half of the non-ventilated ICU patients in this cohort. Even after adjustment for relevant covariates, delirium was found to be an independent predictor of longer hospital stay.     

Analysis of Clostridium difficile-associated diarrhea among patients hospitalized in tertiary care academic hospital

The frequency of Clostridium difficile strains in stool samples of patients with diarrhea hospitalized in the hematology/oncology, surgery, orthopedics, transplantology ward, and emergency room of Davis Medical Center was analyzed. A total of 786 stool samples collected from patients with diarrhea and 180 samples taken from the hospital environment were cultured for C. difficile by routine methods. There were 119 strains of C. difficile isolated: 97 (12.3%) strains from patients' stools (no enteropathogen other than C. difficile was detected in these stool samples) and 22 (12.2%) strains from the hospital environment. It was confirmed that hospital environment plays an important role in transmission of C. difficile by AP-PCR and PCR ribotyping. Among 97 C. difficile strains isolated from patient' stools 25 were nontoxigenic (A-/B-), 67 were toxigenic (A+/B+), and 5 strains were toxin B-positive/toxin A-negative. Analysis of concomitant symptoms among hospitalized patients with diarrhea demonstrated significantly longer duration of diarrhea caused by nontoxigenic strains than in cases of diarrhea caused by toxigenic strains. On the other hand, among patients infected by toxigenic strains, significantly higher leukocytosis and longer duration of fever were observed. The resistance of isolated C. difficile strains to erythromycin and clindamycin indicated the possibility of transmission in the hospital strains with macrolide-lincosamide-streptogramin B resistance type.     

Intensive care unit drug use and subsequent quality of life in acute lung injury patients

OBJECTIVE: To examine the relationship between the use of sedative and neuromuscular blocking agents during a patient's intensive care unit (ICU) stay and subsequent measures of health-related quality of life. DESIGN: Cross-sectional mail survey and retrospective medical record abstraction of a prospectively identified cohort of lung injury patients. SETTING: ICUs in three teaching hospitals in a major metropolitan area. PATIENTS: Patients with acute lung injury (n = 24). INTERVENTIONS: None--observational study. MEASUREMENTS AND MAIN RESULTS: Patients' charts were reviewed for those patients returning postdischarge quality-of-life questionnaires. Duration, daily dose, and route of administration for sedatives and neuromuscular blocking agents were abstracted from ICU flow sheets. Relationships among ICU variables (days of sedation, days of neuromuscular blockade, and severity of illness as measured by Acute Physiology and Chronic Health Evaluation III score) and outcomes (symptoms of depression and symptoms of posttraumatic stress disorder) were assessed. Depressive symptoms at follow-up were correlated with days of sedation (p = .007), but not with days of neuromuscular blockade or initial severity of illness. The composite posttraumatic stress disorder symptom impact score was correlated with days of sedation (p = .006) and days of neuromuscular blockade (p = .035), but not with initial severity of illness. There were no significant differences between the frequency of patients reporting a specific posttraumatic stress disorder symptom in the high sedation group and the low sedation group, and there were no significant differences in specific posttraumatic stress disorder symptoms between the group that had received neuromuscular blockade and those who had not. CONCLUSIONS: The use of sedatives and neuromuscular blocking agents in the ICU is positively associated with subsequent measures of depression and posttraumatic stress disorder symptoms 6-41 months after ICU treatment for acute lung injury.